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pdfOMB No. 0935-0110: Approval Expires 11/30/2020
Medical Expenditure Panel Survey
Insurance Component
2019 HEALTH INSURANCE
COST STUDY
U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU
ACTING AS COLLECTING AGENT FOR
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
29019015
If completing paper form, please RETURN TO:
U.S. Census Bureau
1201 East 10th Street
Jeffersonville, IN 47132-0001 OR Fax to 1-800-447-4613
PLEASE RETURN ENTIRE CONTENTS OF THIS PACKAGE WITHIN
PLEASE DO NOT REMOVE THIS COVER SHEET
FORM MEPS-10 (02-15-2019) Draft 7
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INTERNET RESPONSE
You may respond to this survey via the Internet at the
following secure web address:
econhelp.census.gov/meps
Your Survey Key to access the Internet form is:
2
INSTRUCTIONS
1. Please report for the location identified on the cover sheet, unless
otherwise specified.
2. Please report data for the year 2019.
3. Estimates are acceptable.
4. For an explanation of unfamiliar terms, refer to the MEPS-20(D)
Health Insurance Cost Study definition sheet included with this
package.
5. Unless otherwise specified, respond for ACTIVE employees.
6. Please retain a completed copy of this form for your records.
Collection of this information is authorized under Section 913 of the Public Health Service Act (Title 42
United States Code, Section 299b-2). Section 9 of Title 13, United States Code (the U.S. Census Bureau
Statute), ensures that the information you report to us will be strictly confidential. It may be seen only
by individuals sworn to uphold U.S. Census Bureau confidentiality and may be used only for statistical
purposes.
Paperwork Reduction Act and Burden Statements
We estimate this survey will take 45 minutes, on average, to complete, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If
you offered more than two plans, we estimate an extra 11 minutes per additional plan. You may send any comments regarding
this burden estimate or any other aspect of the collection of information, including suggestions for reducing burden, to the following
address: Director, Center for Financing, Access and Cost Trends, Paperwork Reduction Project 0935-0110, Agency for Healthcare
Research and Quality, 5600 Fishers Lane, Mail Stop 07W41A, Rockville, MD 20857. Please do not mail questionnaires to this
address as it will delay data processing. If the enclosed mailing envelope has been misplaced, please send questionnaire to the
address on the front page of this form.
FORM MEPS-10
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29019023
7. If you have any questions or need assistance in completing the
questionnaire, please call
or visit: econhelp.census.gov/meps
3
NUMBER OF PLANS
Respond for ACTIVE employees only.
1
Did your organization offer any health insurance
plans to its ACTIVE employees at this location
in 2019?
001
1
Yes – Continue with 2
2
No – SKIP to
3
For this survey, a health insurance plan is defined as a
plan where hospital and/or physician coverage is made
available to employees.
2
How many different health insurance plan
choices did your organization offer to its
ACTIVE employees at this location during
the 2019 plan year?
003
Health insurance plan choices at this location
Do not count single service plans (optional plans) such as
dental or vision.
SKIP to 4
• Single, employee-plus-one, and family coverage
providing the same level of benefits from the same
insurance company count as ONE plan.
• High and standard options count as TWO plans.
• An HMO and a PPO from the same insurance
company count as TWO plans.
If your organization did NOT offer health insurance and has
fewer than 50 full-time equivalent employees (see definition
sheet, MEPS-20(D)) continue with Question 3. Otherwise,
SKIP to 4 .
3
Did your organization offer a Qualified Small
Employer Health Reimbursement Arrangement
(QSEHRA) or a Small Business HRA to its
employees?
783
1
Yes
2
No
3
Don’t know
In 2018, did your organization offer any health
insurance plans to its ACTIVE employees at
this location?
741
1
Yes – Offered
2
No – Not offered
3
Don’t know
29019031
4
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PRIOR YEAR OFFERING
Continue with 5
FORM MEPS-10
4
EMPLOYMENT CHARACTERISTICS
Estimates are acceptable for all employment, eligibility, and enrollment figures.
For Questions 5 through 11e, if the answer is NONE, please enter "0".
Include:
• Officers
• Owners
• Full-time and part-time employees
• Temporary and seasonal employees
5
Exclude:
• Former employees
• Leased or contract workers
• Retirees
What was the total number of employees
your organization had at ALL locations for
a typical pay period in 2019?
034
,
Employees at all locations
,
All employees at this
location
Complete Questions 6a through 11e for the location listed on the cover sheet.
6
a. How many employees were on your
200
organization’s payroll AT THIS LOCATION
for a typical pay period?
If your organization did not offer
health insurance in 2019, SKIP to 7a .
b. How many of these employees were
201
ELIGIBLE for at least one health plan
through your organization?
c. How many of these employees were
a. For the same TYPICAL pay period how many
Eligible employees
,
Enrolled employees
,
Part-time employees
202
ENROLLED in any health plan through
your organization?
7
,
203
of the employees reported in Question 6a
worked part-time?
If your organization did not offer
health insurance in 2019, SKIP to 8 .
204
were ELIGIBLE for at least one health plan
through your organization?
c. How many of these part-time employees
How many of the employees reported in
Question 6a worked fewer than 30 hours
per week?
29019049
Is the information you provided in Questions 6
through 8 above for the location listed on the
cover sheet OR did you provide information for
multiple locations?
,
Enrolled part-time employees
,
Employees worked fewer
than 30 hours
742
743
9
Eligible part-time employees
205
were ENROLLED in any health plan through
your organization?
8
,
No employees worked fewer than 30 hours.
550
1
Information for specified location
2
Information for multiple locations
If your organization did not offer
health insurance in 2019, SKIP to 11a .
10
What was the minimum number of hours per
week that an employee had to work in order
to be eligible for health insurance?
626
721
Minimum hours worked per week to be
eligible
No minimum number of hours required.
Continue with 11a
FORM MEPS-10
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b. How many of these part-time employees
5
EMPLOYMENT CHARACTERISTICS - Continued
Provide information for a TYPICAL pay period in 2019.
Estimates are acceptable.
11
a. Approximately what percentage of the
018
employees at this location were union
members?
%
729
b. Approximately what percentage of the
No union members
016
employees at this location were women?
c. Approximately what percentage of the
Union members
%
Women employees
%
Employees 50 years old or older
%
Earned less than $12.50 per hour
%
Earned between $12.50 and $30.50
per hour
%
Earned more than $30.50 per hour
017
employees at this location were 50 years
old or older?
d. For the employees at this location,
approximately what percentage earned –
022
Less than $12.50 per hour?
Approximately $26,000 a year or less . . . . . . . . . . . . . . . . . .
023
Between $12.50 and $30.50 per hour?
Approximately $26,000 to $63,000 a year . . . . . . . . . . . . . . .
024
More than $30.50 per hour?
Approximately $63,000 a year or more . . . . . . . . . . . . . . . . . .
1 0 0
e. For the employees at this location,
%
726
approximately how many earned more
than $47.50 per hour?
,
Number of employees that earned
more than $47.50 per hour
Approximately $99,000 a year or more
FRINGE BENEFITS CHARACTERISTICS
Did your organization offer the following fringe
benefits to its employees at this location?
29019056
If Paid Time Off (PTO) is offered, mark (X) Yes for paid
vacation AND paid sick leave.
Yes
(1)
050
Paid vacation. . . . . . . . . . . . . . . . . .
051
Paid sick leave . . . . . . . . . . . . . . . . .
052
Life insurance . . . . . . . . . . . . . . . . .
053
Disability insurance . . . . . . . . . . . . .
054
Retirement/pension plans . . . . . . . . .
Don’t
No know
(2)
(3)
Continue with 13
FORM MEPS-10
§>"{Y¤
12
6
FRINGE BENEFITS CHARACTERISTICS - Continued
13
Did your organization offer any of these
tax-advantaged benefits to its employees at
this location?
See the definition sheet MEPS-20(D) included with this
package for an explanation of these benefits.
Yes
(1)
627
Employee contributions to health
insurance made on a pre-tax basis. .
056
Flexible Spending Accounts
(FSA) for healthcare. . . . . . . . . . . . .
057
Flexible Benefits Plans. . . . . . . . . . .
Full cafeteria plans that offer
employees a set of benefits
from which to choose.
Don’t
No know
(2)
(3)
If your organization offered health insurance, continue with 14 .
If your organization DID NOT offer health insurance, SKIP to 21 .
HEALTH INSURANCE EXCHANGES AND INSURANCE BROKERS
14
Did your organization offer health insurance to
active employees through a private exchange
(also known as a corporate exchange)?
765
A private exchange is created by a consulting company,
insurance carrier, or other private organization, not by either
a federal or state government. Private exchanges often allow
employees to choose from several health insurance options
offered on the exchange.
Did your organization use a third party, such
as an insurance broker or agent, to help
purchase the insurance plan(s)?
Yes
2
No
3
Don’t know
If your organization has more than 100 employees at all
locations, SKIP to 16a . Otherwise, continue with 15 .
770
1
Yes
2
No
3
Don’t know
29019064
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15
1
Continue with 16a
FORM MEPS-10
7
GENERAL HEALTH COVERAGE CHARACTERISTICS - Continued
16
a. Which of the listed optional coverage services,
if any, did your organization offer to its active
employees at this location, at a premium
SEPARATE from the comprehensive health
plan premium?
}
192
Dental
193
Vision
194
Prescription drugs
Do not include single services covered under a comprehensive health plan.
195
Long-term care
Long-term care insurance helps cover the cost of institutional and home care required by the chronically ill or
disabled.
562
No optional coverage – SKIP to 17
Report single service insurance plans only.
Continue with 16b
Mark (X) all that apply.
720
$
coverage for all active employees during a
TYPICAL MONTH at this location?
18
Did your organization provide any financial
compensation or incentives to employees if
they did not elect to receive health insurance
coverage through your organization?
Were employees’ SPOUSES eligible for health
insurance coverage through your organization?
197
723
745
29019072
19
Did your organization impose a waiting
period before new employees could be covered
by health insurance?
20
,
.00
Monthly total optional coverage cost
Include both employer and employee contributions.
17
,
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
5
All spouses eligible, HIGHER employee
contribution paid if spouse eligible through
own employer.
6
All spouses eligible, SAME employee
contribution.
7
All spouses eligible, don’t know employee
contribution.
2
Limited spouses eligible, only if not offered
by own employer.
3
No spouses eligible.
4
Don’t know
Did your organization offer health insurance
coverage to UNMARRIED domestic partners?
Yes
(1)
730
Same sex domestic partners . . . . . .
731
Opposite sex domestic partners . . . .
Don’t
No know
(2)
(3)
Continue with 21
FORM MEPS-10
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b. What was the total amount paid for optional
8
RETIREE HEALTH COVERAGE CHARACTERISTICS
Please complete Questions 21 through 23g for ALL LOCATIONS. If the answer is NONE, please enter "0".
Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws. See the definition sheet
MEPS-20(D) included with this package for an explanation of these terms.
Did your organization provide health
insurance coverage to any person who
retired in 2019 OR BEFORE, or to any
of their survivors?
551
If COBRA was the only coverage offered, mark "No."
22
In a typical month, how many retirees
were enrolled in health insurance through
your organization at all locations?
Yes – Continue with 22
2
No
3
Don’t know
UNDER 65 YEARS OF AGE
628
reported in Question 22, under 65
years of age or age 65 or older?
1
Yes
2
No
3
Don’t
know
572
number of retirees, by age category,
enrolled in health insurance through
your organization at all locations?
c. What percentage of these retirees, by
573
%
e. For this same plan, what was the
TOTAL monthly premium, by age
category, for this typical retiree with
SINGLE coverage?
29019080
f.
For a typical plan, how much did the
EMPLOYER contribute, by age category,
toward the monthly plan premium for
one typical retiree with FAMILY
coverage?
}
SKIP to
second
column
Percent of
under 65
enrolled
in single
1
Yes
2
No
3
Don’t
know
578
}
SKIP to
24a
Total
65 or
older
,
579
%
Percent of
65 or older
enrolled
in single
580
574
EMPLOYER contribute, by age category,
toward the monthly plan premium for one
typical retiree with SINGLE coverage?
AGE 65 OR OLDER
629
Total
under
65
,
age category, were ENROLLED in
SINGLE coverage?
d. For a typical plan, how much did the
Number of retirees enrolled
,
a. Were any of the enrolled retirees,
b. In a typical month, what was the TOTAL
}
SKIP to the bottom of page 9
to complete form.
513
If this was a self-insured plan, report the premium
equivalent.
23
1
$
,
.00
$
,
.00
$
,
.00
$
,
.00
$
,
.00
581
575
$
,
.00
582
576
$
,
.00
For retirees, if premium varied by family size, report
for a family of two.
g. For this same plan, what was the
TOTAL monthly premium, by age
category, for this typical retiree with
FAMILY coverage?
577
583
$
,
.00
Continue with 24a
FORM MEPS-10
§>"{q¤
21
9
RETIREE HEALTH COVERAGE CHARACTERISTICS – Continued
NEW RETIREES
For Questions 24a through 24c, NEW RETIREES refers only to persons who retired from your organization in 2019.
Exclude any retirees that have coverage through COBRA or state continuation-of-benefits laws.
630
24
1
Yes – Continue with 24b
2
No
a. Did your organization offer health insurance to
any NEW RETIREES?
b. Were NEW RETIREES under 65 years of age
3
Don’t know
1
Yes
2
No
3
Don’t know
1
Yes
2
No
3
Don’t know
631
eligible for health insurance?
c. Were NEW RETIREES age 65 or older eligible
632
for health insurance?
500
}
SKIP to the bottom of this
page to complete form.
Remarks
PERSON COMPLETING THIS QUESTIONNAIRE
Name (Please print)
Title (Please print)
213
Area code
Number
220
215
MM
DD
YYYY
214
–
29019098
Extension
–
–
*** PLEASE NOTE ***
If your organization offered health insurance, please complete the attached
MEPS-10(S), Plan Information Questionnaire, for each plan offered (up to four plans).
If your organization DID NOT offer health insurance, you have completed the survey.
PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS
FORM MEPS-10
§>"{¥¤
212
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |